An hCG level between 6 and 24 mIU/mL is considered a grey area, and you'll likely need to be retested to see if your levels rise to confirm a pregnancy. The rate of increase slows as pregnancy progresses and typically plateaus around 100,000 mIU per mL (100,000 IU per L) at 10 weeks' gestation.16 A decrease in -hCG of at least 21% over 48 hours suggests a likely failed intrauterine pregnancy, whereas a smaller decrease should raise concern for ectopic pregnancy.17, The discriminatory level is the -hCG level above which an intrauterine pregnancy is expected to be seen on transvaginal ultrasonography; it varies with the type of ultrasound machine used, the sonographer, and the number of gestations. A history of ectopic pregnancies or a history of surgery on the fallopian tubes are the factors that most increase the risk. In this case, the pregnancy is called a pregnancy of unknown location. There is no consensus about the next steps if a pregnancy is of unknown location. A 50- or 120-mcg dose is recommended before 12 weeks' gestation, although 300 mcg can be administered if lower doses are not available.3 After 12 weeks, a 300-mcg dose should be given.12, Measurement of serum progesterone may be useful in distinguishing between an early viable or nonviable pregnancy, especially in the setting of inconclusive ultrasonography. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Methotrexate may be used if the pregnancy has not ruptured a fallopian tube. Some experience a small amount of vaginal bleeding or spotting, but others dont. Read common questions on the coronavirus and ACOGs evidence-based answers. PID is usually caused by a sexually transmitted infection that spreads from the vagina to the uterus and fallopian tubes. Accessed Dec. 4, 2019. This can be a life-threatening emergency that needs immediate surgery. Losing a pregnancy is devastating, even if you've only known about it for a short time. An ectopic pregnancy is a pregnancy that happens outside of your uterus. It can take time for the level of hCG in your body to drop after treatment for an ectopic pregnancy. People who have had a history of pelvic inflammatory disease (PID) also have a higher risk for an ectopic pregnancy. These medications can affect the way methotrexate works in the body. For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month. Four weeks postoperatively, serum -HCG levels had a . The search included meta-analyses, guidelines, and reviews. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. information highlighted below and resubmit the form. Interventions for non-tubal ectopic pregnancy. Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. "hCG helps the body produce hormones to support pregnancy," explains John Zhang, M.D., founder. Mayo Clinic does not endorse companies or products. It is not intended as a statement of the standard of care. At-home urine tests require higher levels of hCG to detect a pregnancy, typically at least 20 mIU/mL. 2020;101(10):599-606. https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html, Long Y, Zhu H, Hu Y, et al. Sometimes, the tissue in or around the fallopian tubes is more difficult to identify on an ultrasound image. The estimated mortality of ectopic pregnancy is between 2 and 4/1000. Therefore, in a desired pregnancy, it is recommended that a discriminatory level as high as 3,500 mIU per mL (3,500 IU per L) be used to avoid misdiagnosis and interruption of a viable pregnancy, although most pregnancies will be visualized by the time the -hCG level reaches 1,500 mIU per mL.18,19. A folate antagonist, it interrupts the rapidly dividing cells of the ectopic pregnancy, which are then resorbed by the body.22 Its success rate decreases with higher initial -hCG levels (Table 3).23 Contraindications to methotrexate include renal insufficiency; moderate to severe anemia, leukopenia, or thrombocytopenia; liver disease or alcoholism; active peptic ulcer disease; and breastfeeding.5 Therefore, a complete blood count and comprehensive metabolic panel should be obtained before it is administered. This content is owned by the AAFP. Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. In cases where methotrexate is contraindicated or not preferred by the patient, surgical management can usually be performed laparoscopically if the patient is hemodynamically stable. Are you being treated for any other medical conditions? Approximately one-fourth of pregnant women will experience bleeding in the first trimester. To prevent life-threatening complications, the ectopic tissue needs to be removed. In a desired pregnancy, -hCG levels and serial ultrasonography combined with patient reports of pain or bleeding guide management.20 In an undesired pregnancy or when the possibility of a viable intrauterine pregnancy has been excluded, manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. You may seek medical attention due to pain or vaginal bleeding. As an ectopic pregnancy grows, more serious symptoms may develop, especially if a fallopian tube ruptures. Uterine aspiration should be considered to evaluate for intrauterine chorionic villi in patients with a pregnancy of unknown location. Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. Human chorionic gonadotropin (hCG) is a hormone thats very important throughout pregnancy. There's some overlap between the possible trends in hCG levels for normal and ectopic pregnancies. 25th ed. In 95% of ectopic pregnancy cases, a good transvaginal ultrasound examination can actually image the ectopic pregnancy in the Fallopian tube. All Rights Reserved. For this test, a wandlike device is placed into your vagina. Review/update the Other instruments can be used with it to perform surgery. An ectopic pregnancy is when a fertilized ovum implants outside of the uterus. Correa-de-Araujo R, Yoon SS (Sarah). Terms and Conditions of Use, Get the latest on COVID-19, pregnancy, and breastfeeding. Typical hCG Doubling Times. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Typically, if you go to your health care provider with concerns like this, they will order an ultrasound. Take time to work through your feelings. A wide variety of symptoms are associated with an ectopic pregnancy. Ononuju CN, Ogbe AE, Changkat LL, et al. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. You may continue to feel pregnant for a while. Seek care right away if you have symptoms of a rupture, including sudden abdominal pain, shoulder pain, or weakness. An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. In: Williams Obstetrics. . In stable patients, close monitoring of symptoms, serial quantitative -hCG testing, and ultrasonography are recommended4 (Figure 28,10,14,15 ). Advanced ectopic pregnancy (high -hCG level, large mass, embryonic cardiac activity) Ultrasonography shows gestational sac with mean diameter 25 mm and no yolk sac or embryo, Complete passage of all products of conception, Nonviable intrauterine pregnancy within the first 12 6/7 weeks of gestation, A pregnancy outside the uterine cavity (most commonly in a fallopian tube), Ultrasonography shows embryo with crown-rump length 7 mm and no cardiac activity, Some, but not all, of the products of conception have passed, Intrauterine pregnancy of uncertain viability, Transvaginal ultrasonography shows intrauterine gestational sac with no embryonic cardiac activity (and no findings of definite pregnancy failure [, Pregnancy that cannot result in live birth (e.g., ectopic pregnancy, early pregnancy loss), Positive urine or serum pregnancy test with no intrauterine or ectopic pregnancy shown on transvaginal ultrasonography, More than two consecutive pregnancy losses, Spontaneous loss of pregnancy before 20 weeks' gestation, Bleeding before 20 weeks' gestation in the presence of an embryo with cardiac activity and a closed cervix, Pregnancy that can potentially result in a live birth, Gestational sac (measured by mean sac diameter), Appears four to five weeks after last menstrual period, Mean sac diameter of 16 to 24 mm and no embryo, Appears 5.5 weeks after last menstrual period, Absence of embryo with cardiac activity seven to 10 days after ultrasonography shows gestational sac and yolk sac, Absence of embryo withcardiac activity 11 days after ultrasonography shows gestational sac and yolk sac, Embryo (measured by crown-rump length and embryonic cardiac activity), Appears six weeks after last menstrual period; embryonic cardiac activity appears at 6.5 weeks, Crown-rump length < 7 mm and no embryonic cardiac activity, Crown-rump length 7 mm and no embryonic cardiac activity. Make a donation. 2019;14(8):e0219351. It does not explain all of the proper treatments or methods of care. Hemorrhage was the leading cause of death. The differential diagnosis includes threatened abortion, early pregnancy loss, and ectopic pregnancy. Its not always possible to see an embryo either inside the uterus or in another location. A speculum examination can help identify nonobstetric causes of bleeding, such as vaginitis, cervicitis, or a cervical polyp. Ectopic pregnancies happen when a fertilized egg implants somewhere outside of the uterus, like the fallopian tube or the cervix. About one half of all women who have an ectopic pregnancy do not have known risk factors. . HCG levels alone do not diagnose an ectopic pregnancy. You can detect hCG in either blood or urine . Patient preference should guide treatment decisions. Treatment of threatened abortion is expectant management. There is a problem with McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. This can be done laparoscopically or through an abdominal incision (laparotomy). If so, is it more or less than your typical period? Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. Failure to detect an intrauterine pregnancy, combined with -hCG levels higher than the discriminatory level, should raise concern for early pregnancy loss or ectopic pregnancy. Heres what to know. Ask your ob-gyn or other health care professional to recommend a counselor. As the pregnancy grows, it can cause the tube to burst (rupture). 2019;74. doi:10.6061/clinics/2019/e1111. Clinics. Ectopic pregnancies occur in approximately 1.3 to 2.4% of pregnancies. doi:10.1371/journal.pone.0219351, Nio-Kobayashi J, Abidin HBZ, Brown JK, et al. All women who may conceive should be counseled to take folic acid. It can be helpful to jot down your questions for the doctor before your visit. Randomized trials have shown no difference in sequelae between methotrexate administration and fallopian tubesparing laparoscopic surgery, including rates of future intrauterine pregnancy and risk of future ectopic pregnancy.29 The decision whether to remove the fallopian tube or leave it in place depends on the extent of damage to the tube (evaluated intraoperatively) and the patient's desire for future fertility. If you are pregnant, you can detect it in your urine. Patients should be informed that expectant management is more than 90% effective. Ruptured ectopic pregnancy is associated with peritoneal signs and requires emergency surgery, although most patients present with bleeding or pain before rupture.39, Surgical treatment options include salpingectomy or salpingostomy, which are appropriate if the location of the pregnancy is the fallopian tube, but not if there is a less common location. Explore ACOG's library of patient education pamphlets. 25th ed. All Rights Reserved. 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